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The “Medical Model”

Two rules of thumb to increase your comfort in coding and compliance

JOHN RUMPAKIS, O.D., M.B.A.

The term “medical model” is antiquated from my point of view. In school, they don’t teach medical optometry and non-medical optometry; they teach how to examine, diagnose and treat ocular problems, whether they be refractive, medical, binocular or systemic. Period. In fact, I would suggest that perhaps we change the term “medical model” to the “Total Patient Care Model”; thus, truly reflecting what we do: take care of our patients’ problems. Period.

Our gains in stature within the healthcare community as the primary eyecare profession cannot be taken lightly, for the responsibility that comes with increased scope is immense. It means that we are also subject to all of the rules, regulations and liability that accompanies increased scope.

Unfortunately, many of our colleagues skirt providing full optometric care and just deliver the bare minimum of determining the refractive status of a patient with a cursory health examination. Why? I’m not sure, and not one to assume, either.

I can surmise that though O.D.s feel comfortable diagnosing and recommending treatment for their patients, they find the medical record compliance and medical coding issues too confusing to follow and get properly reimbursed for the care that they are trained to provide. Or perhaps it’s that carriers don’t recognize the increased scope of an optometrist today and deny access to patients for medically related eye care.

Though I can’t solve all of these issues, I can provide a few rules of thumb that will help you feel more comfortable in the medical coding and medical record compliance side of things.

Rules of thumb

► Rule #1: For any care to be the responsibility of a medical carrier, the patient must either present with complaints or symptoms of an eye disease or injury, or you must have requested the patient to return at a specific point in time for a specific reason, or another physician has referred the patient to you for a specific medical reason.

► Rule #2: For any care you provide to a patient, be it an office visit, special ophthalmic procedure or a surgical procedure, the rules of medical necessity must be followed. That simply means that your medical record must demonstrate that everything that you are doing is NECESSARY to:

(a) Diagnose a condition

(b) Follow the diagnosis of a condition

(c) Treat a condition

(d) Follow the treatment of a condition

Yes, that means that you must write more and be more specific, but those are the rules. It also, by definition, eliminates much of the audit risk O.D.s face for over- or under-coding the level of office visit, or for excessive testing.

Total patient care

Providing medical services in an optometric practice should be routine for every provider; in fact, just as routine as providing refractive services. We should take pride in our education and knowledge of how to provide the very best in primary and secondary eyecare services.

Following a few basic rules will alleviate anxiety and significantly reduce the risk we have with increased responsibility and regulatory oversight and let us provide the “Total Patient Care Model” to our patients, as they deserve. OM

DR. RUMPAKIS IS FOUNDER, PRESIDENT AND CEO OF PRACTICE RESOURCE MANAGEMENT, INC., A CONSULTING, APPRAISAL AND MANAGEMENT FIRM FOR HEALTHCARE PROFESSIONALS. E-MAIL HIM AT JOHN@PRMI.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL.COM.